Anesthesia: Tumescent technique aids flaps, grafts

Key Points

International report - No longer reserved for liposuction, tumescent anesthesia reduces blood loss, postsurgical pain and risk of side effects when used for excising benign and malignant lesions and performing subsequent surgical reconstructions, an expert says.

"Tumescent anesthesia works very well in liposuction surgery (LSS). It provides us with prolonged anesthesia, lasting 12 to 14 hours, and vasoconstriction, so we can work in an almost completely bloodless field.

"This is also very important in skin cancer," says Enrique Hernández-Pérez, M.D., director of the Center for Dermatology and Cosmetic Surgery in San Salvador, El Salvador, and president of the Meso-American Academy of Cosmetic Surgery.

Compared to the dry technique, including general anesthesia, the tumescent technique also decreases drug absorption, prolonging anesthetic effects while reducing toxicity, he says.

Dr. Hernández-Pérez says when he learned of the tumescent technique during a lecture given by Jeffrey Klein, M.D., in 1986, "He explained that instead of using 7 mg/kg body weight of lidocaine, he used 35 mg/kg. We thought such high concentrations would put patients at risk. Soon thereafter, we learned that Dr. Klein was right, and the situation changed forever."

Over the years, physicians have refined the technique.

"Tumescence means only swelling of the tissues," he says, "so using small volumes of Klein solution is the same as using the wet technique with Klein solution."

Similarly, he says combining tumescent anesthesia with IV sedation does not invalidate the concepts of tumescence. "And if we work in a fully equipped operating room, risks are not increased."

Accordingly, Dr. Hernández-Pérez says he uses the tumescent technique in a wide variety of surgeries requiring prolonged anesthesia and vasoconstriction. These include facelifts, fat transfers, hair transplantation and augmentation mammoplasty.

Conversely, he says nearly all of the reconstructive surgeries he performs result from excisions of various forms of skin cancer, most frequently basal cell carcinomas, squamous cell carcinomas and melanomas.

"When using epinephrine," Dr. Hernández-Pérez says, "it is possible to have some minor tachycardia. But it is possible to avoid this if, one hour before surgery, you give the patient one oral tablet (100 mcg) of clonidine (Catapres, Boehringer Ingelheim)."

Furthermore, one must avoid giving epinephrine to patients on beta blockers (interaction could provoke hypertensive crisis with bradycardia) or aspirin, he says.

While other surgeons also have adapted the tumescent technique to post-excisional reconstructions, Dr. Hernández-Pérez says, "I doubt if anyone else uses it as much as we do in skin cancer."

The technique works well, regardless of tumor size and location, he says, noting that he has used it in areas including the scalp, back, face and limbs.

"For instance, we have removed some malignant melanomas in different parts of the body which required removing at least 3 cm margins around the tumor."

Tumescent anesthesia also provides "amazing results that are clearly superior to common local anesthesia.

"It's difficult to quantify, but working in a bloodless field produces much less scarring and pain," he says.

The tumescent technique likewise reduces post-surgical bleeding. Therefore, "It's very rare to have seromas or hematomas. I have not seen any of these in at least the last 15 years when using tumescent anesthesia," Dr. Hernández-Pérez says.

Disclosure: Dr. Hernández-Pérez reports no relevant financial interests.

For more information: http://www.dermato2007.org/